Introduction
A variety of skin conditions are common in people with chronic kidney disease (CKD) and renal transplants. Skin disorders associated with chronic kidney disease can significantly affect a person's quality of life and mental and physical health.
What Are the Common Skin Conditions Associated With Kidney Disease?
Important skin manifestations related to kidney disease are as follows:
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Half and Half Nails (Lindsay's Nails): This condition, also known as Lindsay's Nails, is seen in 21 % of people on dialysis. Half and half nails clinically manifest as discolored nails with the white coloring of the proximal nail and red-brown coloration of the distal nail. The discoloration of the nail does not change with its growth, indicating the problem starts in the nail bed. The discoloration also does not resolve with pressure. The exact etiology of half-and-half nails is still unknown. Still, it is believed that acidosis and an increase in toxic uremic substances that occurs after sudden renal decompensation may stimulate melanin pigment formation by nail matrix melanocytes. This phenomenon resolves with renal transplantation.
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Xerosis: Xerosis cutis, which describes dry and rough skin, is one of the most common skin conditions in people with chronic renal failure. The condition affects 50 to 85 % of people on dialysis and usually occurs on the anterior legs, back, arms, abdomen, and waist. The main cause of this skin issue is the reduction in the size of eccrine sweat glands and the atrophy of sebaceous glands. People with xerosis usually experience scaling and fissures on the skin. The cracks in the skin can increase the chance of further viral or bacterial infection. Treatment of xerosis mainly involves behavioral changes and the use of topical medications. Avoiding hot water showers and using natural oils for showers instead of harsh soaps helps minimize excess drying and moisturization of the skin. Urea 10 % lotion with Dexpanthenol also decreases scaling and redness in xerosis.
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Nephrogenic Systemic Fibrosis (NSF): It is a rare, systemic fibrotic disease found mainly in advanced renal failure. The exact cause still needs to be fully understood. However, fibrous connective tissue formation in the skin and connective tissues results in tissue scarring throughout the body, mainly in the skin and subcutaneous tissues. Exposure to gadolinium-based contrast agents (GBCAs) during magnetic resonance imaging (MRI) triggers the development of this disorder in people with renal disease. The condition is marked by visible fibrosis of the skin with swelling and tightening of the skin. Fibrotic skin across joints leads to limited joint movement. Sclerotic changes are often observed in the feet, ankles, shins, thighs, fingers, hands, and lower arms. There is no cure and no effective treatment for nephrogenic systemic fibrosis. Certain treatments like hemodialysis, physical therapy, kidney transplant, and extracorporeal photopheresis with ultraviolet A may help. Medications including Pentoxifylline, Imatinib, Sodium thiosulfate, and high-dose intravenous immune globulin may offer some improvement. Prevention of this disease includes avoidance of older gadolinium-based contrast agents.
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Acquired Perforating Dermatosis (APD): This is an uncommon disorder marked by transepidermal elimination of collagen, elastic tissue, or necrotic connective tissue acquired in adulthood. This disease is commonly observed in individuals with end-stage chronic kidney disease, especially those with diabetes mellitus and those receiving hemodialysis. The etiology of APD is unclear, but it is associated with diabetes mellitus, hypothyroidism, liver disease, malignancies, and HIV infection. In addition, minor trauma, such as scratching, microvascular changes associated with diabetes mellitus, and skin calcium accumulation with foreign body inflammatory response, act as triggers for the development of APD. APD is characterized by hyperkeratotic papular lesions predominantly on extensor surfaces of the arms and legs and, less commonly, on the scalp, trunk, and buttocks. The lesions of APD typically resolve in six to eight weeks. If treatment is desired, various options are available. For example, topical or oral retinoids help decrease epidermal thickness, and steroids (topical, oral, or intradermal) help decrease inflammation. In addition, Allopurinol, a xanthine oxidase inhibitor, is proven effective for severe APD cases.
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Non-Melanoma Skin Cancer(NMSC): It is the most common malignancy found in all transplant recipients, and it affects approximately 2.2% of people with renal transplants. Overexposure to ultraviolet (UV) light is the primary cause of non-melanoma skin cancer. The initial signs of non-melanoma skin cancer are often the appearance of a lump or discolored patch on the skin that lasts after a few weeks and slowly progresses over months or sometimes years. Of the two most common types of non-melanoma skin cancer, squamous cell carcinoma is more aggressive in invasion and metastasis than basal cell carcinoma. Squamous cell carcinoma more frequently occurs in renal transplant recipients in areas of the body which are more exposed to skin, including the head and face. Treatment involves complex surgical procedures. Full-body skin examination is essential for the early identification of the lesions. People should be instructed to perform self-examinations routinely, and full-body skin check-ups should be done in regular post-renal transplant follow-up appointments.
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Renal Pruritus: It accounts for 50 to 90% of people with end-stage chronic kidney disease, mainly in individuals on hemodialysis. The cause of renal pruritus is multifactorial. Several factors contribute to the development of renal pruritis, including abnormal metabolism of calcium and phosphorus, abnormal magnesium and aluminum concentrations, systemic inflammation, accumulation of toxins, sprouting of new nerves, co-existing systemic diseases, particularly diabetes and liver disease, and suboptimal dialysis regimen. Itching in renal pruritis can be localized or generalized pruritus, with the back being the most commonly affected site. However, it can also involve the arms, head, and abdomen. Itching often worsens at night, resulting in sleep disruption, and is exacerbated by heat, xerosis, sweating, and stress. In addition, repetitive and severe scratching can result in skin lesions, such as excoriations, lichen simplex, nodular prurigo, and keratotic papules. Treatment involves emollients, ultraviolet phototherapy, and activated charcoal and Nalfurafine to soothe and ease skin itching.
When to See a Doctor?
Contact a healthcare provider right away if the skin feels itchy or irritated. Otherwise, the symptoms may worsen, and it may be challenging to reverse the progression. It is never too soon to talk to a healthcare provider. Detection of renal disease in the early stages can help prevent the progression of the condition and associated complications.
Conclusion
Skin manifestations are common in end-stage chronic kidney disease. These skin conditions can significantly affect a person's quality of life and mental and physical health. Effective and innovative treatments are available for the management of these conditions. Detection of kidney disease in the early stages can help take control of a person's health sooner. People need to recognize the skin manifestations of renal disease to minimize and even prevent the morbidity associated with these conditions.
